Managing unhappy patients after surgery

The idea behind surgery is a really simple one: You come to me with a specific problem, I fix it, you go away happy. And when you come back, you’re still happy. What’s so wrong with that? If I wanted to be miserable, I’d have gone into primary care.

When a surgeon screws up, his/her role is clear: Admit it, make it better, or as good as possible, and stick with it as long as it takes. But what about when you don’t screw up, and the patient is still unhappy? As I indicated last time, in some ways that’s the most difficult situation of all. Once again, it’s complicated: There are bad outcomes or side-effects that result from well-thought-out and well-carried-out surgery; and there are, well, who knows exactly what they are…

As an example of the first sort: It’s possible nowadays, with certain beautifully engineered staplers, to remove a rectal tumor and hook the colon right down to the anus, sparing the patient from a colostomy that would have been a certainty a couple of decades ago. When approaching such an operation, I would always tell the patient that there could be difficulty controlling the bowels, temporarily or, rarely, permanently. Converting to a colostomy later is an outside possibility.

Likewise, it’s not rare for a circular staple-line to scar down to a point where it could need dilating, which is usually a simple office procedure but occasionally requires an anesthetic. Those things are, in fact, pretty straightforward: If the problems occur, the patient might be uncomfortable for awhile (or in the case of poor bowel control, miserable). But it’s a known thing, and not reflective of operator error. And there are fixes. If I’d ever had to convert a hook-up to a colostomy later (I never did), I’d have felt bad for the patient, and no doubt would have encountered disappointment. I could handle it without feeling like a screwup, and likely without losing the patient’s trust.

Somewhere in between this and the most miserable circumstance, is the patient who doesn’t get better. Early in my practice days, I did a textbook perfect thyroid operation for a young man with Grave’s disease (overactive thyroid). Taking out most of his thyroid, successfully avoiding the minefields of damage to laryngeal nerves or parathyroid glands, leaving him the perfect (according to my training) amount of residual gland with which to live without the need for thyroid hormone replacement pills, I felt great about the whole thing.

Six months later, it was as if he’d never had an operation: big neck again, and all the symptoms. For me it was like falling off a nice sailboat into icy water. (And it led me to decide that people are better off taking pills than having a relapse; so I began — without any regret — to remove essentially the whole gland for all my future patients. Hell with what I’d been taught.) Faced with re-operation — more dangerous the second time around — he opted for radiation, which he’d strenuously rejected as an option initially. Feeling bad is bad. I guess it’s better than feeling guilty; but I didn’t like seeing the look on his face. Knowing I did everything right doesn’t change the sense of failure. To me, it’s like a robbery: I feel great about it, I have every right to, and then suddenly it’s all upside down. “Gee, I hope you know I did everything right” is what I want to say. But I don’t.

Sometimes a proper operation makes things worse. Known side effects, like dumping syndrome: It’s like playing great odds and still losing. These can be the times when the surgeon sends the wounded patient back to his primary care doc — or with dumping, to the gastroenterologist — creating ill will all around: Surgeons just operate and leave the problems to someone else. It’s where the stereotype was born, I’d say. In my practice at least, it’s an unfair characterization: I’d do everything I could for as long as I could. But there comes a time when other expertise is likely to be better; when it does, it looks — and feels — bad.

And what of this: I operate, I fix the problem, make it gone. But the patient isn’t happy: I can’t sleep, he says; I get headaches all the time; my bowels are messed up. I’m sweating. Ever since the operation, I’ve been impotent, anorgasmic. My incision still hurts. It’s a long and frustrating list, and it’s likely eventually to lead to an unhappy parting of the ways. “Tie goes to the runner.” “Benefit of the doubt.”

Such things need to be taken seriously; there are a number of known causes for various post-op symptoms. But after enough time, enough tests, enough maneuvers and investigations to have ruled out every imaginable cause, where do you go? What are you to think? Can you broach the subject of psychological cause without producing a pissed-off patient? Like post-partum depression, post-op depression is a known entity, and I’ve used anti-depressants sometimes, to good effect. But it’s a touchy subject. And when that doesn’t work, then what? It’s tempting simply to say, look, I’ve done everything I can, you need to find a new doctor. Some do, I gather from this and other blogs. It really is the hardest of all: There’s no pleasure or satisfaction, there’s no explanation, there’s no graceful exit, no fallback. It makes everyone miserable, the relationship is shot: in every way, it’s the complete opposite of why you’re doing this. It just sucks, that’s all there is to it.

I also mentioned discussing the frustrations of cleaning up another surgeon’s mess. Forget it. I’m already too depressed.

Physician Coaching by KevinMD

Managing unhappy patients after surgery 9 comments

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DeceasedMD1

So nice to hear how a surgeon feels about these really difficult situations. We already know how patients feel.

Dr. Drake Ramoray

“If I’d wanted to be miserable, would have gone into primary care”

I laughed out loud at this, and I’m certainly not saying it isn’t true. A sad state of affairs when one of our consolations is that we aren’t a different kind of doctor.

I remember the days of that kind of thyroid surgery, the same time we were looking for just the right dose of I-131 to make the paient euthyroid. We don’t do that anymore either, for the same reasons.

Good post.

betsynicoletti

I laughed too.

DoubtfulGuest

Doctors, please make sure to differentiate between patients who still feel cruddy after surgery, and patients who still feel cruddy and blame YOU?

I had two surgeries for endometriosis, the first was laparoscopic vaporization. The second, just 8 months later, was TLH/BSO with more laser vaporization. This story ends well…I’ve been symptom free for several years now and I have a good relationship with both doctors involved.

But after that first procedure, it was awkward for awhile. I’d had symptom improvement for just two weeks and was feeling horrible after a couple months on BC pills. At the followup appointment, the resident who took my history said the doc would be “sad that your pain came back”. My doc agreed we could switch to Lupron, but also gave me the sideways look with the raised eyebrow and said if I didn’t improve from there, we’d have to “think about what else might be causing the pain”.

After six more months, she did take me seriously when I said I wasn’t doing well and needed to be done with treatment. I had waited 20 years for diagnosis (in addition to my mitochondrial disease) so she agreed I’d been through enough. They found quite a bit of new endometriosis that had grown in just that short time between the two surgeries. The distribution was consistent with my pain complaints. I had been accused of faking a lot already, so I’d worried continuously about the doctor’s comment after the first procedure. I also felt bad that she felt bad — I never thought there was any shortcoming on her part. Biology is weird. Sometimes weird things happen and it’s no one’s fault.

betsynicoletti

But, in the US, we think all outcomes should be perfect and all problems solved by a pill or a procedure. We don’t want reality to intrude on our fantasies.

medicontheedge

Patients, er, customers, are SOLD that. We in the health care field are selling a product and services, and marketing is loaded with bull short. Are we surprised when customers are not happy? Wait until they start demanding refunds. Oh, wait…..

D.Wang MD MPH

Nice article. Appreciate the author’s honesty. I find that surgeons I work with often don’t ask for help enough, even though I am happy to do it; I think they see it as a sign of weakness perhaps? We all need help with difficult complex patients. It’s less frustrating that way.

Karen Ronk

Surgery is really a very intimate thing in a way. You are allowing a doctor to cut into you and remove/replace/repair often crucial parts of your anatomy. When that surgeon does an inferior or harmful surgery, it affects you on a very deep level – especially when the outcome cannot be reversed. And with sincere respect to the writer of this post and other surgeons, unless it has happened to you personally, there is no way you can understand what it feels like to be damaged in that way.

Margaret Fleming

I followed the link to surgeonsblog and read the outpatient mastectomy post. I love surgeons (and all other folk) with common sense. Thank you.